Investigators from the New York State Department of Health (DOH) recently cited the Indian River Rehabilitation and Nursing Center, a 122-bed facility located in Grandville, New York, for failing to provide adequate treatment to a suicidal patient who died 18 days after being admitted into the center. The DOH report concluded that “the facility did not ensure that a resident who displayed mental or psychological adjustment difficulty received appropriate treatment and services to correct the assessed problem.” In addition, health department surveyors concluded that the facility failed to address the nutritional needs of the patient, who lost 17.8 percent of her body weight over a short period of time.

The resident was admitted into the nursing home on February 4, 2014 and was diagnosed with congestive heart failure and memory difficulties. Upon admittance into the facility, the patient told staff members, “I want to kill myself.” Staff members checked on the resident every 15 minutes, and a social worker determined that the patient did not have a “plan” to commit suicide. On February 16, 2014, a certified nursing assistant (CNA) was assigned to watch the resident in her room during the night. The CNA stated that the patient was extremely agitated. At one point, the resident stated that she wanted to kill herself and tried to choke herself with her hands. After trying to put her hand down her throat, the resident then began to bang her head against a table. When the CNA told a licensed practical nurse (LPN) about the resident’s suicidal remarks and behavior, the LPN notified the nursing supervisor who decideded to give the patient anti-anxiety medication. The LPN told the supervisor that the medication usually had little effect on the patient, but the supervisor ordered it anyway. The supervisor never notified the physician about the resident’s suicidal ideations, as is required by the facility’s internal policies.

Even after receiving the medication, the patient was still agitated. When the CNA began pushing the resident in her wheelchair towards the bathroom, the patient quickly lunged herself forward and fell onto the floor and hit her head. The CNA immediately notified other staff members, who found the patient to be bleeding from her nose. The patient suffered a facial fracture as the result of the fall. DOH investigators determined that the “RNS [Registered Nurse Supervisor] did not assess resident when medication was not effective in managing behaviors. RNS did not follow facility protocol regarding suicidal ideation.”

In addition, health inspectors determined that the nursing home failed to address the resident’s significant weight loss over a period of 18 days. The resident weighed 165.8 pounds when she was admitted into the facility. On four occasions, staff members weighed the patient and documented that she was losing weight. On February 15, 2014, the resident only weighed 138.7 pounds. A dietitian stated that she was never notified of the patient’s condition.